Lecture 18: Headaches Flashcards
What type of headache is the most common?
What gender are headaches most common in?
tension type headaches
females
What ocular disorders can you get a secondary headache from?
- acute glaucoma,
- refractive error
- heterophoria/tropia
- ocular inflammation
- Trauma
6.Vascular - Raised ICP
What types of primary headaches can you get?
Migraine
* Tension type headache
* Trigeminal autonomic cephalalgias (cluster headache)
* Other primary headache disorders
What are the 5 phases of a migraine?
- Premonitory symptoms - affects 60%
- Aura - affects 20%
- Headache - affects 80%
- Termination
- Postdrome
What are the premonitory symptoms you can get for migraines?
An awareness that an attack is going to happen
psychological symptoms:
* depression, euphoria, mental slowness, hyperactivity
neurologic phenomena
* photophobia, phonophobia
* nausea / vomiting
general
* coldness, loss of appetite, food cravings
What are the features of aura in a migraine?
Develops over 5 - 20 minutes
Normally lasts less than 60 minutes
- ‘Prolonged aura’ last up to a week
- The effects of a ‘migranous infarction will last longer
Focal neurological symptoms:
Sensory:
* visual, auditory, numbness, tingling
* Heightened sensitivity
Motor:
* ophthalmoplegia, hemiplegia
What is visual aura?
What are the signs?
Retinal migraine in which the symptoms are purely uniocular
Teichopsia
* Fortification spectra
- Hemianopia
- scintillating scotomata
- Water running down the windscreen
- Heat haze
- Broken up / cracked mirror
- “Tunnel vision”
- Very rarely total visual loss
When is the onset of the headache in migraines?
How long does it last?
What are the symptoms?
What is it associated with?
60 mins after aura finishes
4-72 hours
moderate to severe
pulsating
unilateral
aggravated by movement
photophobia or phonophobia
* poor concentration
* nausea, vomiting
What is typical aura like with a non-migraine headache?
What must you rule out?
visual,sensory, speech symptoms
Gradual development
* No longer than one hour
* Mix of positive and negative features
* Complete reversibility
* Absence of typical headache associated with migraine
transient ischaemic attack
What is the pathophysiology of a migraine?
What are the external triggers?
What are the visual triggers?
Thought to be vascular in origin
* vessel constriction corresponds to
aura
* vessel dilation corresponds to headache
* Pain from Intra-cranial, extra-cerebral vessels
- Physiological trigger unknown
- Genetic influence
- many have positive family history
- Tiredness, certain foods or drinks, bright lights
glare (sun reflections, windows)
Flicker (flashlights, stroboscopes, TV or cinema)
Patterns (text)
What is the management of migraines?
If obvious diagnosis, letter of information to GP
* Reassurance
* not life threatening
* not associated with serious illness
* exception can be young women on ‘the pill’
* no known cure
- Write a ‘headache diary’
- to identify and avoid triggers
- Medication
- pain relief during acute attack
- preventative if > 5 attacks per month
What are the types of tension headaches you can get?
What are the features and symptoms of a tension headache?
What is it associated with?
Episodic or chronic
* Last 30 mins to 7 days
- Bilateral
- Occipital, parietal or posterior neck
- Tightness/pressing/band-like (but not pulsating)
- Mild to moderate – does not stop daily activities
- Not made worse by routine physical activity
- May be associated with photophobia and phonophobia
- No nausea/vomiting
- Associated with sleeplessness, stress or emotional conflict
- Differential diagnosis with migraine difficult
What is the pathophysiology of a tension headache?
What is the management?
muscle contraction
associated with psychological problems
routine referral to GP
What is trigeminal autonomic cephalgias?
What are the signs?
Who does it effect more?
Pain on one side of the head in area of the trigeminal nerve
cluster headaches
1-8 attacks over a period of days or weeks
* may be associated with facial flushing, conjunctival injection, eyelid oedema, rhinorrhea, pupil constriction and partial ptosis
Starts around one eye or cheek
* Spreads across head
* Reaches a peak in a few minutes
* Lasts 30 minutes - a few hours
* Intense pain
* Sufferers bang head against wall
* Burn head with hot compresses
* Wakes patient in early hours
men x6 more than females
What is the pathophysiology of trigeminal autonomic cephalgias?
What is the management?
Cause unknown,
* no demonstrable pathology
*fMRI:
* Hypothalamic activity
refer to GP
prophylactic meds
analgesics
What vascular pathology can cause a headache?
temporal arteritis
Aneurysm
Arteriovenous malformation
What age is temporal arteritis more likely?
What is another name for it?
What are the signs?
What are the systemic associations?
What is the pathophysiology?
over 60
female>male
giant cell arteritis
-Headache normally constant
* Gradual onset to a diffuse severe aching
* Superficial scalp tenderness – temporal
* Worse at night and in the cold
* Jaw claudication
fever, anaemia, weight loss, polymyalgia rheumatica
What are the ocular signs of temporal arteritis?
AION
* Partial or total infarction of optic
nerve head
* Occlusion of short posterior ciliary arteries
ARTERITIC:
* Usually inferior altitudinal
hemianopia
* Related to Giant Cell Arteritis GCA
- CRAO
- Amaurosis Fugax
What is the management of temporal arteritis?
OPHTHALMIC EMERGENCY
* Risk of visual loss in other eye (70% within 10 days)
* Risk of cerebral vascular accident
* Temporal artery biopsy
* MRI and Doppler study
* Erythrocyte sedimentation rate (ESR)
* C-reactive protein levels
* Treated with high doses of oral steroids
* Visual acuity does not recover
What are the signs of an aneurysm headache?
What is the management?
sudden, excruciating headache
* stiff neck
* vomiting
* altered behaviour
* may have focal lesions
* IIIrd nerve palsy if posterior
communicating artery affected
* hemiparesis if the middle cerebral artery affected
immediate referral to A&E
What are the signs of arteriovenous malformation?
Management?
- Specific recurring headache
- Ruptured AVM or fistula
- sudden severe headache
- stiff neck
- homonymous field defect typical of occipital AVM
immediate referral to A&E
What are the headache characteristics of raised ICP?
- normally intermittent
- non-specific, non localised
- dull, not throbbing
- worse after exercise
- may waken patient from sleep
- transient headache on coughing
- may be absent
What are the signs of papilloedema?
Management?
Mild disc swelling and hyperaemia
* nasal margins affected first
* Venous engorgement
* Blurring of disc margins and peripapillary RNFL
* Loss of spontaneous venous pulsation
refer to casualty
What are the symptoms of a headache caused by uncorrected rx/incorrect rx?
What are the symptoms of a headache caused by heterophoria//hetrotropia?
- Not present on waking
- Mild HA
- Frontal, around eyes
- Recurrent
- Mild HA
- Intermiaent blur/diplopia
- May be relieved by closing one eye
What is trigeminal neuralgia?
Management?
- Affects distribution of trigeminal nerve (Vth nerve)
- intense jabs of pain, repetitive
- lasts only seconds, with an ache in between
- Mostly affects mandibular or maxillary region
- Can affect ophthalmic division, but not in isolation * Onset usually after age 50 years
-atypical facial pain
routine referral to GP
